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- Good-quality patient-oriented evidence
- Inconsistent or limited-quality patient-oriented evidence
- Consensus, usual practice, opinion, disease-oriented evidence, case series
STEPS key: Tolerability/Simplicity: low=less tolerable/more complex; high=more tolerable/less complex.
Osteoarthritis (OA) is a common, almost expected, part of getting old. Some patients require no treatment or have symptoms that are easily controlled with over-the-counter analgesics or nonsteroidal anti-inflammatory drugs (NSAIDs) and lifestyle modifications. Others are so debilitated that surgery is the only way to go.
Where does that leave elderly patients in between—those who don’t make good surgical candidates or find little relief from basic interventions and want to “try everything” before surgery?
The best way to answer this question is to utilize the STEPS (Safety, Tolerability, Efficacy, Price, and Simplicity) format, a helpful mnemonic for an objective way to evaluate drugs or medical therapies.1
The recommendations, strength of recommendation (SOR) ratings, and summaries that follow are presented in this format, and draw upon recent reviews, focused studies, and scholarly analysis provided by the Osteoarthritis Research Society International (OARSI). The interventions are divided into 3 categories:
- over-the-counter remedies
- nonpharmacologic interventions
- injections/prescription drugs.
Over-the-counter remedies
Capsaicin ointment
Recommended (SOR: A).
Safety: High.
Tolerability: Medium. About 50% of patients experience a local (and possibly intense) burning sensation initially, but it generally wanes after several weeks. The number needed to harm (NNH) is about 10 for withdrawal due to adverse effects.2
Efficacy: Medium. Evidence regarding topical capsaicin comes mostly from studies of patients with musculoskeletal conditions in general, not OA specifically. About 40% of patients treated with capsaicin report a 50% decrease in musculoskeletal pain, as do 25% of those using a placebo (number needed to treat [NNT]=8).2
Price: Low. About $15 per month per joint.
Simplicity: Medium. Patients need to apply the ointment 3 or 4 times a day.
Tell patients, too, to use topical capsaicin for a few weeks before evaluating its effectiveness or deciding whether to abandon it. Emphasize that it should be used for base pain rather than for acute pain relief. (For those who can’t tolerate capsaicin, topical salicylate may offer similar benefits.)
Glucosamine
Recommended with or without chondroitin (SOR: B).
Safety: High.
Tolerability: High. Side effects are rare.
Efficacy: Low. There have been numerous trials of glucosamine alone (chondroitin alone is not recommended), mostly limited to knee pain. While many have found that glucosamine offers little or no clinical benefit, some have shown a benefit comparable to or slightly better than acetaminophen. Overall, evidence suggests that up to 40% of those who take glucosamine achieve a clinically significant response,3-5 although the placebo response may be substantial.
One study found that glucosamine was effective only when it was combined with chondroitin, and only when pain was more than mild.6 Another showed no clinical benefit for hip OA.7 There is limited evidence for or against the use of glucosamine and chondroitin to slow disease progression; the 2 agents are not recommended for this purpose.
Price: Low to medium ($5-$35 per month).
Simplicity: Medium to high; patients should take glucosamine (or glucosamine and chondroitin) 3 times a day. Compliance is likely to be variable, depending on results.
Evaluate after 4 months, and advise patients to discontinue if there is no significant improvement. Tell them, too, that while preparations vary by manufacturer and price, the difference between the various products is too small to justify the cost of the higher-priced brands.
Nonpharmacologic interventions
Acupuncture
Not recommended (SOR: A).
Safety: High.
Tolerability: Medium to high. Discomfort from the needles varies from slight to none.
Efficacy: Zero to low. Several studies have indicated some beneficial effect, but the degree of improvement has been small, with a sizable placebo effect.8 Studies typically include weekly sessions over the course of several months, and have demonstrated up to a 20% improvement in pain and function; however, much of that improvement has been attributed to the placebo effect, as demonstrated by studies that compared acupuncture with a sham procedure.8 Most data on acupuncture involve the knee; there is insufficient information about the procedure’s efficacy for other sites and for shorter treatment periods.
Price: Medium to high, approaching $1000 for a series of weekly sessions over 3 to 4 months.
Simplicity: Medium. Frequent office visits are standard. Long-term compliance is likely to be low, given the small benefit and the inconvenience.
Knee braces
Recommended (SOR: C).
Safety: High.
Tolerability: Medium to high. Tolerance depends on the type of brace and its complexity.
Efficacy: Low to medium. Few studies of knee bracing have been done; however, 1 trial showed that 73% of those who used sophisticated taping for 3 weeks reported improvement, vs 10% of no-tape controls.9 Pain decreased by 2 points on a 0- to 10-point scale at 3 weeks, and the benefit persisted for an additional 3 weeks after the taping was discontinued. The taping used in the study is impractical for usual and long-term use, but 45% of those who used a sham taping/wrap reported improvement and about a 1-point decrease in pain at 3 and 6 weeks. This suggests that a less sophisticated wrap, such as an elastic patellar-stabilization sleeve, is likely to provide some benefit.
Price: Low (generally less than $30).
Simplicity: High (for a basic sleeve or wrap).
TENS
Recommended (SOR: B).
Safety/Tolerability: High. Withdrawals due to adverse effects of transcutaneous electrical nerve stimulation (TENS) range from 0% to 14%.10
Efficacy: Medium. The mean improvement with TENS is about 20 points more (on a 100-point scale) than the effect associated with placebo; the data are based on knee OA pain that is moderate to severe. The effect may last 2 to 4 weeks; however, there have been few long-term studies of the benefits of TENS.
Price: Low to medium, depending on availability and insurance coverage.
Simplicity: Medium; TENS units can be used at home, but some patients may be uncomfortable using the apparatus.
Injections/prescription drugs
Corticosteroid injections
Recommended (SOR: A).
Safety: High for short-term use, but data on the degree and frequency of acute post-injection pain is limited. The possibility of harm from repeated injections is similarly uncertain, although 1 study of patients receiving 8 injections over a 2-year period found no progression in ill effects compared with patients receiving placebo.11
Tolerability: Medium to high. Discomfort from the needle is usually mild.
Efficacy: Low to medium. Critical analysis supports a modest benefit, with an NNT of 2 to 3 for short-term improvement (lasting 3-4 weeks).12,13 In 1 study, steroid injections produced an average of a 16-point reduction in pain on a 100-point scale. After 1 month, the benefit from the injection is usually not clinically significant.
Price: Low ($100-$200 per injection).
Simplicity: High. The injection itself is a relatively simple procedure, but patient compliance with a scheduled course of repeat injections is uncertain.
Hyaluronic acid (HA) injections
Recommended with caveats (SOR: A).
Safety: High.
Tolerability: Medium. A small number of patients experience a transitory local flare-up. In addition, some patients have an aversion to injections.
Efficacy: Low. Several recent meta-analyses and systematic reviews of HA injections for knee OA have found a small, often negligible, clinical effect, with placebo usually accounting for up to half of the reported benefit.14-18 In 1 study with no control group, however, patients experienced about a 60% decrease in composite pain score—and 75% were satisfied or very satisfied with the treatment.19 Studies of HA injection for hip OA are very limited, but a recent single-injection trial showed no benefit over placebo.20
Any benefit from an HA injection generally lasts 3 to 4 months.
Price: Medium-high. A course of 3 injections costs $700 to $1000 per joint. There are claims of substantial savings due to delayed joint replacement, but these are speculative.
Simplicity: Medium. Compliance (completing all 3 injections) was high in clinical trials, but is uncertain otherwise. However, injections may frequently be useless because the joint space isn’t entered. One study found that 29% of knee injections were extra-articular; placement was uncertain in another 5%. There was no correlation between successful placement and presumed expertise. This error is not surprising, considering that the articular space is usually narrowed and patients being treated for joint pain are often obese. Being able to aspirate fluid increases the chance of proper placement. (While placement errors may also occur with corticosteroid injections, that possibility is offset by a lower cost and somewhat greater likelihood of beneficial effect.)
- Consider this option only for patients with high-function goals and substantial pain or disability.
- Proceed cautiously with morbidly obese patients and patients without effusion.
- Opt for bacterial HA (Euflexxa), which has been found to be the most cost effective and have the highest efficacy and the fewest adverse effects; evidence suggests that hylan (Synvisc) should be avoided.15,16
HA injections can be repeated every 6 to 12 months if they prove to be highly beneficial. Advise patients, however, that data on repeated courses of the injections are very limited.
Nonsteroidal anti-inflammatory gel or patch
Not recommended (SOR: B).
Safety: High. Absorption is minimal, but there may be some systemic effects.
Tolerability: Medium to high, although some patients develop skin reactions to the patch and the gel.
Efficacy: Low. Pain reduction of up to 50% has been reported, but most of it is attributed to the placebo effect. The actual effect of the gel or patch averages only about 10%.21-24
Price: Medium. The gel sells for $150 to $180 per month for a quantity large enough to be used on 2 hands or 1 knee; the patch is similarly priced.
Simplicity: Low. Manufacturers recommend that the gel be applied 4 times a day, but this can prove difficult over the long term. The patch is applied only twice a day, but the painful area is usually too large or irregular for the patch to cover.
Narcotics for refractory pain
Recommended (SOR: B).
Safety: Medium. The elderly are particularly vulnerable to narcotics’ adverse effects, but the incidence of addiction and abuse in geriatric patients is very low. Recently released guidelines on the management of persistent pain from the American Geriatrics Society recommend that all older patients with moderate to severe pain or diminished quality of life be considered for narcotic therapy.25
Tolerability: Medium. Noncompliance is associated with side effects, which are usually dose-dependent. These include constipation, somnolence, and mental status changes. Reported noncompliance rates vary, in some cases reaching as high as 30%.26
Efficacy: Low to medium for weak narcotics (eg, codeine, tramadol), with about a 10% decrease in pain.26,27 However, studies generally suffer from small numbers of patients, short duration, inconsistency among clinical trials, and limited evaluation of disability and quality of life. One good study of tramadol users showed about a 15% decrease in pain among “young elders”—the total decrease in pain was 30%, including the placebo effect. Sleep quality improved and tolerability was high, with no increase in withdrawal due to adverse effects.28 For stronger narcotics (eg, morphine), direct evidence of efficacy for OA pain is lacking, but it seems reasonable to expect a medium benefit. Low-to-moderate daily doses of opioids for chronic noncancer pain—including arthritis—have been shown to improve the quality of life, compared with no narcotics or high doses.29
Price: Low (less than $20/month) for hydrocodone with acetaminophen; medium to high (more than $150/month) for long-acting morphine and transdermal fentanyl.
Simplicity: Medium to high. Twice-a-day dosing is available for long-acting strong opioids, but some narcotics must be taken 4 times a day.
What else can you do? Encourage activity—again
A clear conclusion from many studies is that nonaquatic exercise involving the affected joints, either specifically or as part of a general exercise routine, is clinically beneficial in decreasing pain and increasing function.30 When it comes to aquatic exercises for OA, the data are very limited, but suggest a small short-term benefit.31 Overall, the optimal type and duration of exercise for OA patients, as well as the best location (home or at a gym), is not known.
If your patient has stopped or markedly cut down on the time spent exercising, explore the feasibility of another attempt, and discuss ways to improve compliance. Stress the “bonus” benefits of exercise, such as mood elevation and an overall sense of well-being. If the patient is not undergoing physical therapy, consider a referral.
Use a chronic pain approach
Patients whose OA symptoms continue to be troublesome may benefit from a chronic pain syndrome approach. Nurse case management, phone contact, and extra attention from you may be helpful, along with educational material that the patient can consult between visits (PATIENT HANDOUT).32
Treat insomnia. Studies are insufficient for hypnotics for OA symptoms, but good sleep is a goal of standard pain management. Cognitive-behavioral therapy has been found to be helpful in alleviating sleep problems in patients with OA.33 At a minimum, take a good sleep history and provide basic sleep hygiene education.
Treat vitamin deficiency and depression. Many elderly patients are deficient in vitamin D, and evidence indicates that supplementation supports muscle strengthening and may aid in pain reduction. The effects are mostly preventive, however, and therefore not easily appreciated, so stress the importance of long-term health.
Depression, too, is common among the elderly, particularly for chronic pain patients. If you prescribe antidepressants or vitamin supplementation, emphasize that they are “for your arthritis.”
Inspect footwear. Despite several studies regarding the effects of shoes with inserts on knee OA, it is unclear whether they provide clinical benefit. OARSI supports insoles for selected patients, but acknowledges that evidence is weak. Advise patients to select shoes that are flexible yet supportive and that moderately priced shoes appear to be as good as more expensive footwear for most OA patients. A podiatry consult may be beneficial for patients who have deformities of the feet or complain of foot pain.
Consider assistive devices. Patients with OA who are unstable may benefit from the use of a cane, walker, or other assistive device. Use common sense and individualize treatment, in consultation with an occupational therapist, if necessary.
Living with arthritis: Do’s and Don’ts
Osteoarthritis is an inflammation of the joint that affects many people as they age, mainly in the knees, hips, and hands. After many years of use, the cartilage that lines the inside of the joint thins and eventually wears off, leaving bone rubbing on bone. At the edge of the joint, the bone may grow into small “spurs” and fluid may increase inside, causing inflammation and pain.
There is no cure for arthritis. But there are many things that you and your doctor can do to make arthritis easier to live with, and to slow its progression. These Do’s and Don’ts may help:
Do get moving. Exercising your arthritic joints, except during acute flare-ups, will strengthen the muscles and help you stay active. Eventually you’ll find that you’re in less pain and can move about more easily.
Do consult a physical therapist to find out what type of exercise is best for you. Ask your doctor for a referral.
Don’t do those exercises during painful flare-ups. This is the time to give your joints a rest.
Do take acetaminophen (Tylenol), as needed, especially during flare-ups. You can take up to 4000 mg a day, but be sure to tell your doctor if you’re taking acetaminophen regularly.
Don’t take acetaminophen without first consulting your doctor if you have liver or kidney disease—or you’re taking a prescription pain medication.
Do ask your doctor about nonsteroidal anti-inflammatory drugs, sometimes called NSAIDs (pronounced N-SEDs). Some people benefit from ibuprofen (Advil, Motrin) or naproxen (Aleve), which are sold over-the-counter. Others take prescription NSAIDs such as Celebrex.
Don’t take NSAIDs without consulting your doctor if you’re over the age of 65. Both prescription and nonprescription NSAIDs can have serious side effects, and should be used with caution, if at all, by older people.
Do consider a trial of glucosamine (1500 mg daily), with or without chondroitin (1200 mg daily). Take it every day for 3 or 4 months without making other changes in treatment before you decide whether it’s working.
Don’t buy an expensive brand of glucosamine. The extra cost probably isn’t worth it.
Don’t take chondroitin without glucosamine, as it is unlikely to help.
Do apply ointments and rubs for pain relief. Start with capsaicin, which is available without a prescription. Buy the lowest strength you can find, and start by applying a very small amount on a small area because it may cause a burning sensation in the beginning. If you can’t tolerate capsaicin ointment, try a salicylate rub instead.
Do consider corticosteroid injections if you continue to have a lot of pain in your knee, especially if the doctor finds that you have fluid build-up. (If you don’t want to be injected with a steroid, ask your doctor if you’re a candidate for injections of hyaluronic acid, an artificial joint fluid that may help some patients.)
Do try TENS (transcutaneous electrical nerve stimulation) if you continue to have severe hip or knee pain. TENS therapy may be administered by a physical therapist, or with a device that you can use at home. A pad that emits a small tingle of electricity is placed over the painful joint to relieve the pain.
Do talk to your doctor about narcotic pain medication if your pain continues to be severe.
ADDITIONAL SELF-CARE TIPS:
Do try a wrap-around knee brace, which you can purchase at your local pharmacy. Ask your doctor about getting a cane or a walker if you need additional support.
Do alert your physician to certain conditions that can make your arthritis pain worse—insomnia, depression, or foot problems, for instance. And, if you have ill-fitting shoes or shoes that don’t provide much support, it’s time to replace them.
Joint replacement: When or whether?
Patients who are considering joint replacement surgery or are interested in learning more about it need a realistic picture of what to expect. Explain that results are usually—but not always—very favorable. However, surgery often brings greater improvement in pain than in function, and recovery can be very strenuous and lengthy. Infection rates average 1%,34,35 and mortality rates are low. In a large study of veterans, the 30-day mortality rates after knee and hip arthroplasty were 0.6% and 0.7%, respectively,36 but thromboembolic complications may occur despite prophylaxis. Overall, 5% of those undergoing joint replacement surgery develop significant complications.34,35
Knowing what surgery entails and the difficult recovery required may help patients be more tolerant of their OA symptoms. Whatever treatment your patients opt for, empathy on your part will help, as well.
CORRESPONDENCE
James Crosby, MD, United Health Services, Wilson Family Medicine Residency, 40 Arch Street, Johnson City, NY 13790; [email protected]
1. Ebell M, Siwek J. AFP: Doing more to help you get the best evidence. Am Fam Physician. 2004;69:483-484.
2. Mason L, Moore RA, Derry S, et al. Systematic review of topical capsaicin for the treatment of chronic pain. BMJ. 2004;228:991.-
3. Fox BA, Schmitz E, Wallace R. Glucosamine and chondroitin for osteoarthritis, Family Practice Inquires Network Clinical Inquires. Am Fam Physician. 2006;73:1245-1247.
4. Towheed TE, Maxwell L, Anastassiades TP, et al. Glucosamine therapy for treating osteoarthritis. Cochrane Database Syst Rev. 2005;(2):CD002946.-
5. Herrero-Beaumont G, Ivorra JA, Del Carmen TM, et al. Glucosamine sulfate in the treatment of knee osteoarthritis symptoms. Arthritis Rheum. 2007;56:555-567.
6. Clegg DO, Reda D, Harris CL, et al. Glucosamine, chrondroitin sulfate, and the two in combination for painful knee osteoarthritis. N Engl J Med. 2006;354:795-808.
7. Rozendaal RM, Koes BW, von Osch GJ, et al. Effect of glucosamine sulfate on hip osteoarthritis: a randomized trial. Ann Intern Med. 2008;148:268-277.
8. Manheimer E, Linde K, Lao L, et al. Meta-analysis: acupuncture for OA of the knee. Ann Intern Med. 2007;146:868-877.
9. Hinman RS, Crossley KM, McConnell J, et al. Efficacy of knee tape in the management of osteoarthritis of the knee: blinded randomised controlled trial. BMJ. 2003;327:135.-
10. Bjordal JM, Johnson MI, Lopes-Martins RA, et al. Short-term efficacy of physical interventions in osteoarthritic knee pain. A systematic review and meta-analysis of randomised placebo-controlled trials. BMC Musculoskelet Disord. 2007;8:51.-
11. Raynauld JP, Buckland-Wright C, Ward R, et al. Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial. Arthritis Rheum. 2003;48:370-377.
12. Arroll B, Goodinyear-Smith F. Corticosteroid injections for osteoarthritis of the knee: meta-analysis. BMJ. 2004;328:869-873.
13. Palacios L, Jones W, Mayo H. Do steroid injections help with osteoarthritis of the knee? J Fam Pract. 2004;53:921-922.
14. Bellamy N, Campell J, Robinson V, et al. Viscosupplementation for the treatment of osteoarthritis of the knee. Cochrane Database Syst Rev. 2006;(2):CD005321.-
15. Arrich J, Piribauer F, Mad P, et al. Intra-articular hyaluronic acid for the treatment of osteoarthritis of the knee: systematic review and meta-analysis. CMAJ. 2005;172:1039-1043.
16. Medina JM, Thomas A, Denegar CR. Knee osteoarthritis: should your patient opt for hyaluronic acid injection? J Fam Pract. 2006;55:669-675.
17. Modawal A, Fley J, Shukla R, et al. Hyaluronic acid injections relieve knee pain. J Fam Pract. 2005;54:758-767.
18. Waddell DD. Viscosupplementation with hyaluronans for osteoarthritis of the knee: clinical efficacy and economic implications. Drugs Aging. 2007;24:629-642.
19. Kichner M, Marshall D. A double-blind randomized controlled trial comparing alternate forms of high molecular weight hyaluronan for treatment of osteoarthritis of the knee. Osteoarthritis Cartilage. 2006;14:154-162.
20. Richette P, Ravaud P, Conrozier T, et al. Effect of hyaluronic acid in symptomatic hip osteoarthritis: a multicenter, randomized, placebo-controlled trial. Arthritis Rheum. 2009;60:824-830.
21. Underwood M. Advice to use topical or oral ibuprofen for chronic knee pain in older people: randomized controlled trial and patient preference study. BMJ. 2008;336:138-142.
22. Diclofenac gel for osteoarthritis. Medical Letter. 2008;50:31-32.
23. Lin J, Zhang W, Jones A, et al. Efficacy of topical non-steroidal anti-inflammatory drugs in the treatment of osteoarthritis: meta-analysis of randomized controlled trials. BMJ. 2004;329:324-329.
24. A diclofenac patch for pain. Medical Letter. 2008;50:1-2.
25. American Geriatrics Society. American Geriatrics Society announces new guidelines to improve pain management, quality of life, and quality of care for older patients. May 1, 2009. Available at: http://www.americangeriatrics.org/news/pain043009.shtml. Accessed June 1, 2009.
26. Peloso PM. Opioid therapy for osteoarthritis of the hip and knee: use it or lose it? J Rheum. 2001;28:6-10.
27. Bannwarth B. Letter: Opioids for osteoarthritis of the hip and knee: which opioids for which patients? J Rheum. 2001;28:1930-1931.
28. Vorsanger G, Xiang J, Jordan D, et al. Post hoc analysis of a randomized, double blind, placebo-controlled efficacy and tolerability study of tramadol extended release for the treatment of osteoarthritis pain in geriatric patients. Clin Ther. 2007;29:2520-2535.
29. Dillie KS, Fleming MF, Mundt MP, et al. Quality of life associated with daily opioid therapy in a primary care chronic pain sample. J Am Board Fam Med. 2008;21:108-117.
30. Fransen M, McConnell S, Bell M. Exercise for osteoarthritis of the hip or knee. Cochrane Database Syst Rev. 2003;(3):CD004376.-
31. Bartels EM, Lund H, Hagen KB, et al. Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database Syst Rev. 2007;(4):CD005523.-
32. Rosemann T, Joos S, Laux G, et al. Case management of arthritis patients in primary care: a cluster-randomized controlled trial. Arthritis Rheum. 2007;57:1390-1397.
33. Vitiello M. CBT for insomnia may reduce osteoarthritis pain. Poster presented at: 60th Annual Meeting of the Gerontological Society of America; November 16-20, 2007; San Francisco, Calif.
34. Erens G, Thronhill T. Complications of total hip arthroplasty. In: Basow DS, ed. UpToDate. Waltham, Mass: UpToDate; 2009. Available at: http://www.uptodate.com. Accessed May 20, 2009.
35. Martin G, Thornhill T. Complications of total knee arthroplasty. In: Basow DS, ed. UpToDate. Waltham, Mass: UpToDate; 2009. Available at: http://www.uptodate.com. Accessed May 20, 2009.
36. Ibrahim SA, Stone RA, Han X, et al. Racial/ethnic differences in surgical outcomes in veterans following knee and hip arthroplasty. Arthritis Rheum. 2005;52:3143-3151.
- Good-quality patient-oriented evidence
- Inconsistent or limited-quality patient-oriented evidence
- Consensus, usual practice, opinion, disease-oriented evidence, case series
STEPS key: Tolerability/Simplicity: low=less tolerable/more complex; high=more tolerable/less complex.
Osteoarthritis (OA) is a common, almost expected, part of getting old. Some patients require no treatment or have symptoms that are easily controlled with over-the-counter analgesics or nonsteroidal anti-inflammatory drugs (NSAIDs) and lifestyle modifications. Others are so debilitated that surgery is the only way to go.
Where does that leave elderly patients in between—those who don’t make good surgical candidates or find little relief from basic interventions and want to “try everything” before surgery?
The best way to answer this question is to utilize the STEPS (Safety, Tolerability, Efficacy, Price, and Simplicity) format, a helpful mnemonic for an objective way to evaluate drugs or medical therapies.1
The recommendations, strength of recommendation (SOR) ratings, and summaries that follow are presented in this format, and draw upon recent reviews, focused studies, and scholarly analysis provided by the Osteoarthritis Research Society International (OARSI). The interventions are divided into 3 categories:
- over-the-counter remedies
- nonpharmacologic interventions
- injections/prescription drugs.
Over-the-counter remedies
Capsaicin ointment
Recommended (SOR: A).
Safety: High.
Tolerability: Medium. About 50% of patients experience a local (and possibly intense) burning sensation initially, but it generally wanes after several weeks. The number needed to harm (NNH) is about 10 for withdrawal due to adverse effects.2
Efficacy: Medium. Evidence regarding topical capsaicin comes mostly from studies of patients with musculoskeletal conditions in general, not OA specifically. About 40% of patients treated with capsaicin report a 50% decrease in musculoskeletal pain, as do 25% of those using a placebo (number needed to treat [NNT]=8).2
Price: Low. About $15 per month per joint.
Simplicity: Medium. Patients need to apply the ointment 3 or 4 times a day.
Tell patients, too, to use topical capsaicin for a few weeks before evaluating its effectiveness or deciding whether to abandon it. Emphasize that it should be used for base pain rather than for acute pain relief. (For those who can’t tolerate capsaicin, topical salicylate may offer similar benefits.)
Glucosamine
Recommended with or without chondroitin (SOR: B).
Safety: High.
Tolerability: High. Side effects are rare.
Efficacy: Low. There have been numerous trials of glucosamine alone (chondroitin alone is not recommended), mostly limited to knee pain. While many have found that glucosamine offers little or no clinical benefit, some have shown a benefit comparable to or slightly better than acetaminophen. Overall, evidence suggests that up to 40% of those who take glucosamine achieve a clinically significant response,3-5 although the placebo response may be substantial.
One study found that glucosamine was effective only when it was combined with chondroitin, and only when pain was more than mild.6 Another showed no clinical benefit for hip OA.7 There is limited evidence for or against the use of glucosamine and chondroitin to slow disease progression; the 2 agents are not recommended for this purpose.
Price: Low to medium ($5-$35 per month).
Simplicity: Medium to high; patients should take glucosamine (or glucosamine and chondroitin) 3 times a day. Compliance is likely to be variable, depending on results.
Evaluate after 4 months, and advise patients to discontinue if there is no significant improvement. Tell them, too, that while preparations vary by manufacturer and price, the difference between the various products is too small to justify the cost of the higher-priced brands.
Nonpharmacologic interventions
Acupuncture
Not recommended (SOR: A).
Safety: High.
Tolerability: Medium to high. Discomfort from the needles varies from slight to none.
Efficacy: Zero to low. Several studies have indicated some beneficial effect, but the degree of improvement has been small, with a sizable placebo effect.8 Studies typically include weekly sessions over the course of several months, and have demonstrated up to a 20% improvement in pain and function; however, much of that improvement has been attributed to the placebo effect, as demonstrated by studies that compared acupuncture with a sham procedure.8 Most data on acupuncture involve the knee; there is insufficient information about the procedure’s efficacy for other sites and for shorter treatment periods.
Price: Medium to high, approaching $1000 for a series of weekly sessions over 3 to 4 months.
Simplicity: Medium. Frequent office visits are standard. Long-term compliance is likely to be low, given the small benefit and the inconvenience.
Knee braces
Recommended (SOR: C).
Safety: High.
Tolerability: Medium to high. Tolerance depends on the type of brace and its complexity.
Efficacy: Low to medium. Few studies of knee bracing have been done; however, 1 trial showed that 73% of those who used sophisticated taping for 3 weeks reported improvement, vs 10% of no-tape controls.9 Pain decreased by 2 points on a 0- to 10-point scale at 3 weeks, and the benefit persisted for an additional 3 weeks after the taping was discontinued. The taping used in the study is impractical for usual and long-term use, but 45% of those who used a sham taping/wrap reported improvement and about a 1-point decrease in pain at 3 and 6 weeks. This suggests that a less sophisticated wrap, such as an elastic patellar-stabilization sleeve, is likely to provide some benefit.
Price: Low (generally less than $30).
Simplicity: High (for a basic sleeve or wrap).
TENS
Recommended (SOR: B).
Safety/Tolerability: High. Withdrawals due to adverse effects of transcutaneous electrical nerve stimulation (TENS) range from 0% to 14%.10
Efficacy: Medium. The mean improvement with TENS is about 20 points more (on a 100-point scale) than the effect associated with placebo; the data are based on knee OA pain that is moderate to severe. The effect may last 2 to 4 weeks; however, there have been few long-term studies of the benefits of TENS.
Price: Low to medium, depending on availability and insurance coverage.
Simplicity: Medium; TENS units can be used at home, but some patients may be uncomfortable using the apparatus.
Injections/prescription drugs
Corticosteroid injections
Recommended (SOR: A).
Safety: High for short-term use, but data on the degree and frequency of acute post-injection pain is limited. The possibility of harm from repeated injections is similarly uncertain, although 1 study of patients receiving 8 injections over a 2-year period found no progression in ill effects compared with patients receiving placebo.11
Tolerability: Medium to high. Discomfort from the needle is usually mild.
Efficacy: Low to medium. Critical analysis supports a modest benefit, with an NNT of 2 to 3 for short-term improvement (lasting 3-4 weeks).12,13 In 1 study, steroid injections produced an average of a 16-point reduction in pain on a 100-point scale. After 1 month, the benefit from the injection is usually not clinically significant.
Price: Low ($100-$200 per injection).
Simplicity: High. The injection itself is a relatively simple procedure, but patient compliance with a scheduled course of repeat injections is uncertain.
Hyaluronic acid (HA) injections
Recommended with caveats (SOR: A).
Safety: High.
Tolerability: Medium. A small number of patients experience a transitory local flare-up. In addition, some patients have an aversion to injections.
Efficacy: Low. Several recent meta-analyses and systematic reviews of HA injections for knee OA have found a small, often negligible, clinical effect, with placebo usually accounting for up to half of the reported benefit.14-18 In 1 study with no control group, however, patients experienced about a 60% decrease in composite pain score—and 75% were satisfied or very satisfied with the treatment.19 Studies of HA injection for hip OA are very limited, but a recent single-injection trial showed no benefit over placebo.20
Any benefit from an HA injection generally lasts 3 to 4 months.
Price: Medium-high. A course of 3 injections costs $700 to $1000 per joint. There are claims of substantial savings due to delayed joint replacement, but these are speculative.
Simplicity: Medium. Compliance (completing all 3 injections) was high in clinical trials, but is uncertain otherwise. However, injections may frequently be useless because the joint space isn’t entered. One study found that 29% of knee injections were extra-articular; placement was uncertain in another 5%. There was no correlation between successful placement and presumed expertise. This error is not surprising, considering that the articular space is usually narrowed and patients being treated for joint pain are often obese. Being able to aspirate fluid increases the chance of proper placement. (While placement errors may also occur with corticosteroid injections, that possibility is offset by a lower cost and somewhat greater likelihood of beneficial effect.)
- Consider this option only for patients with high-function goals and substantial pain or disability.
- Proceed cautiously with morbidly obese patients and patients without effusion.
- Opt for bacterial HA (Euflexxa), which has been found to be the most cost effective and have the highest efficacy and the fewest adverse effects; evidence suggests that hylan (Synvisc) should be avoided.15,16
HA injections can be repeated every 6 to 12 months if they prove to be highly beneficial. Advise patients, however, that data on repeated courses of the injections are very limited.
Nonsteroidal anti-inflammatory gel or patch
Not recommended (SOR: B).
Safety: High. Absorption is minimal, but there may be some systemic effects.
Tolerability: Medium to high, although some patients develop skin reactions to the patch and the gel.
Efficacy: Low. Pain reduction of up to 50% has been reported, but most of it is attributed to the placebo effect. The actual effect of the gel or patch averages only about 10%.21-24
Price: Medium. The gel sells for $150 to $180 per month for a quantity large enough to be used on 2 hands or 1 knee; the patch is similarly priced.
Simplicity: Low. Manufacturers recommend that the gel be applied 4 times a day, but this can prove difficult over the long term. The patch is applied only twice a day, but the painful area is usually too large or irregular for the patch to cover.
Narcotics for refractory pain
Recommended (SOR: B).
Safety: Medium. The elderly are particularly vulnerable to narcotics’ adverse effects, but the incidence of addiction and abuse in geriatric patients is very low. Recently released guidelines on the management of persistent pain from the American Geriatrics Society recommend that all older patients with moderate to severe pain or diminished quality of life be considered for narcotic therapy.25
Tolerability: Medium. Noncompliance is associated with side effects, which are usually dose-dependent. These include constipation, somnolence, and mental status changes. Reported noncompliance rates vary, in some cases reaching as high as 30%.26
Efficacy: Low to medium for weak narcotics (eg, codeine, tramadol), with about a 10% decrease in pain.26,27 However, studies generally suffer from small numbers of patients, short duration, inconsistency among clinical trials, and limited evaluation of disability and quality of life. One good study of tramadol users showed about a 15% decrease in pain among “young elders”—the total decrease in pain was 30%, including the placebo effect. Sleep quality improved and tolerability was high, with no increase in withdrawal due to adverse effects.28 For stronger narcotics (eg, morphine), direct evidence of efficacy for OA pain is lacking, but it seems reasonable to expect a medium benefit. Low-to-moderate daily doses of opioids for chronic noncancer pain—including arthritis—have been shown to improve the quality of life, compared with no narcotics or high doses.29
Price: Low (less than $20/month) for hydrocodone with acetaminophen; medium to high (more than $150/month) for long-acting morphine and transdermal fentanyl.
Simplicity: Medium to high. Twice-a-day dosing is available for long-acting strong opioids, but some narcotics must be taken 4 times a day.
What else can you do? Encourage activity—again
A clear conclusion from many studies is that nonaquatic exercise involving the affected joints, either specifically or as part of a general exercise routine, is clinically beneficial in decreasing pain and increasing function.30 When it comes to aquatic exercises for OA, the data are very limited, but suggest a small short-term benefit.31 Overall, the optimal type and duration of exercise for OA patients, as well as the best location (home or at a gym), is not known.
If your patient has stopped or markedly cut down on the time spent exercising, explore the feasibility of another attempt, and discuss ways to improve compliance. Stress the “bonus” benefits of exercise, such as mood elevation and an overall sense of well-being. If the patient is not undergoing physical therapy, consider a referral.
Use a chronic pain approach
Patients whose OA symptoms continue to be troublesome may benefit from a chronic pain syndrome approach. Nurse case management, phone contact, and extra attention from you may be helpful, along with educational material that the patient can consult between visits (PATIENT HANDOUT).32
Treat insomnia. Studies are insufficient for hypnotics for OA symptoms, but good sleep is a goal of standard pain management. Cognitive-behavioral therapy has been found to be helpful in alleviating sleep problems in patients with OA.33 At a minimum, take a good sleep history and provide basic sleep hygiene education.
Treat vitamin deficiency and depression. Many elderly patients are deficient in vitamin D, and evidence indicates that supplementation supports muscle strengthening and may aid in pain reduction. The effects are mostly preventive, however, and therefore not easily appreciated, so stress the importance of long-term health.
Depression, too, is common among the elderly, particularly for chronic pain patients. If you prescribe antidepressants or vitamin supplementation, emphasize that they are “for your arthritis.”
Inspect footwear. Despite several studies regarding the effects of shoes with inserts on knee OA, it is unclear whether they provide clinical benefit. OARSI supports insoles for selected patients, but acknowledges that evidence is weak. Advise patients to select shoes that are flexible yet supportive and that moderately priced shoes appear to be as good as more expensive footwear for most OA patients. A podiatry consult may be beneficial for patients who have deformities of the feet or complain of foot pain.
Consider assistive devices. Patients with OA who are unstable may benefit from the use of a cane, walker, or other assistive device. Use common sense and individualize treatment, in consultation with an occupational therapist, if necessary.
Living with arthritis: Do’s and Don’ts
Osteoarthritis is an inflammation of the joint that affects many people as they age, mainly in the knees, hips, and hands. After many years of use, the cartilage that lines the inside of the joint thins and eventually wears off, leaving bone rubbing on bone. At the edge of the joint, the bone may grow into small “spurs” and fluid may increase inside, causing inflammation and pain.
There is no cure for arthritis. But there are many things that you and your doctor can do to make arthritis easier to live with, and to slow its progression. These Do’s and Don’ts may help:
Do get moving. Exercising your arthritic joints, except during acute flare-ups, will strengthen the muscles and help you stay active. Eventually you’ll find that you’re in less pain and can move about more easily.
Do consult a physical therapist to find out what type of exercise is best for you. Ask your doctor for a referral.
Don’t do those exercises during painful flare-ups. This is the time to give your joints a rest.
Do take acetaminophen (Tylenol), as needed, especially during flare-ups. You can take up to 4000 mg a day, but be sure to tell your doctor if you’re taking acetaminophen regularly.
Don’t take acetaminophen without first consulting your doctor if you have liver or kidney disease—or you’re taking a prescription pain medication.
Do ask your doctor about nonsteroidal anti-inflammatory drugs, sometimes called NSAIDs (pronounced N-SEDs). Some people benefit from ibuprofen (Advil, Motrin) or naproxen (Aleve), which are sold over-the-counter. Others take prescription NSAIDs such as Celebrex.
Don’t take NSAIDs without consulting your doctor if you’re over the age of 65. Both prescription and nonprescription NSAIDs can have serious side effects, and should be used with caution, if at all, by older people.
Do consider a trial of glucosamine (1500 mg daily), with or without chondroitin (1200 mg daily). Take it every day for 3 or 4 months without making other changes in treatment before you decide whether it’s working.
Don’t buy an expensive brand of glucosamine. The extra cost probably isn’t worth it.
Don’t take chondroitin without glucosamine, as it is unlikely to help.
Do apply ointments and rubs for pain relief. Start with capsaicin, which is available without a prescription. Buy the lowest strength you can find, and start by applying a very small amount on a small area because it may cause a burning sensation in the beginning. If you can’t tolerate capsaicin ointment, try a salicylate rub instead.
Do consider corticosteroid injections if you continue to have a lot of pain in your knee, especially if the doctor finds that you have fluid build-up. (If you don’t want to be injected with a steroid, ask your doctor if you’re a candidate for injections of hyaluronic acid, an artificial joint fluid that may help some patients.)
Do try TENS (transcutaneous electrical nerve stimulation) if you continue to have severe hip or knee pain. TENS therapy may be administered by a physical therapist, or with a device that you can use at home. A pad that emits a small tingle of electricity is placed over the painful joint to relieve the pain.
Do talk to your doctor about narcotic pain medication if your pain continues to be severe.
ADDITIONAL SELF-CARE TIPS:
Do try a wrap-around knee brace, which you can purchase at your local pharmacy. Ask your doctor about getting a cane or a walker if you need additional support.
Do alert your physician to certain conditions that can make your arthritis pain worse—insomnia, depression, or foot problems, for instance. And, if you have ill-fitting shoes or shoes that don’t provide much support, it’s time to replace them.
Joint replacement: When or whether?
Patients who are considering joint replacement surgery or are interested in learning more about it need a realistic picture of what to expect. Explain that results are usually—but not always—very favorable. However, surgery often brings greater improvement in pain than in function, and recovery can be very strenuous and lengthy. Infection rates average 1%,34,35 and mortality rates are low. In a large study of veterans, the 30-day mortality rates after knee and hip arthroplasty were 0.6% and 0.7%, respectively,36 but thromboembolic complications may occur despite prophylaxis. Overall, 5% of those undergoing joint replacement surgery develop significant complications.34,35
Knowing what surgery entails and the difficult recovery required may help patients be more tolerant of their OA symptoms. Whatever treatment your patients opt for, empathy on your part will help, as well.
CORRESPONDENCE
James Crosby, MD, United Health Services, Wilson Family Medicine Residency, 40 Arch Street, Johnson City, NY 13790; [email protected]
- Good-quality patient-oriented evidence
- Inconsistent or limited-quality patient-oriented evidence
- Consensus, usual practice, opinion, disease-oriented evidence, case series
STEPS key: Tolerability/Simplicity: low=less tolerable/more complex; high=more tolerable/less complex.
Osteoarthritis (OA) is a common, almost expected, part of getting old. Some patients require no treatment or have symptoms that are easily controlled with over-the-counter analgesics or nonsteroidal anti-inflammatory drugs (NSAIDs) and lifestyle modifications. Others are so debilitated that surgery is the only way to go.
Where does that leave elderly patients in between—those who don’t make good surgical candidates or find little relief from basic interventions and want to “try everything” before surgery?
The best way to answer this question is to utilize the STEPS (Safety, Tolerability, Efficacy, Price, and Simplicity) format, a helpful mnemonic for an objective way to evaluate drugs or medical therapies.1
The recommendations, strength of recommendation (SOR) ratings, and summaries that follow are presented in this format, and draw upon recent reviews, focused studies, and scholarly analysis provided by the Osteoarthritis Research Society International (OARSI). The interventions are divided into 3 categories:
- over-the-counter remedies
- nonpharmacologic interventions
- injections/prescription drugs.
Over-the-counter remedies
Capsaicin ointment
Recommended (SOR: A).
Safety: High.
Tolerability: Medium. About 50% of patients experience a local (and possibly intense) burning sensation initially, but it generally wanes after several weeks. The number needed to harm (NNH) is about 10 for withdrawal due to adverse effects.2
Efficacy: Medium. Evidence regarding topical capsaicin comes mostly from studies of patients with musculoskeletal conditions in general, not OA specifically. About 40% of patients treated with capsaicin report a 50% decrease in musculoskeletal pain, as do 25% of those using a placebo (number needed to treat [NNT]=8).2
Price: Low. About $15 per month per joint.
Simplicity: Medium. Patients need to apply the ointment 3 or 4 times a day.
Tell patients, too, to use topical capsaicin for a few weeks before evaluating its effectiveness or deciding whether to abandon it. Emphasize that it should be used for base pain rather than for acute pain relief. (For those who can’t tolerate capsaicin, topical salicylate may offer similar benefits.)
Glucosamine
Recommended with or without chondroitin (SOR: B).
Safety: High.
Tolerability: High. Side effects are rare.
Efficacy: Low. There have been numerous trials of glucosamine alone (chondroitin alone is not recommended), mostly limited to knee pain. While many have found that glucosamine offers little or no clinical benefit, some have shown a benefit comparable to or slightly better than acetaminophen. Overall, evidence suggests that up to 40% of those who take glucosamine achieve a clinically significant response,3-5 although the placebo response may be substantial.
One study found that glucosamine was effective only when it was combined with chondroitin, and only when pain was more than mild.6 Another showed no clinical benefit for hip OA.7 There is limited evidence for or against the use of glucosamine and chondroitin to slow disease progression; the 2 agents are not recommended for this purpose.
Price: Low to medium ($5-$35 per month).
Simplicity: Medium to high; patients should take glucosamine (or glucosamine and chondroitin) 3 times a day. Compliance is likely to be variable, depending on results.
Evaluate after 4 months, and advise patients to discontinue if there is no significant improvement. Tell them, too, that while preparations vary by manufacturer and price, the difference between the various products is too small to justify the cost of the higher-priced brands.
Nonpharmacologic interventions
Acupuncture
Not recommended (SOR: A).
Safety: High.
Tolerability: Medium to high. Discomfort from the needles varies from slight to none.
Efficacy: Zero to low. Several studies have indicated some beneficial effect, but the degree of improvement has been small, with a sizable placebo effect.8 Studies typically include weekly sessions over the course of several months, and have demonstrated up to a 20% improvement in pain and function; however, much of that improvement has been attributed to the placebo effect, as demonstrated by studies that compared acupuncture with a sham procedure.8 Most data on acupuncture involve the knee; there is insufficient information about the procedure’s efficacy for other sites and for shorter treatment periods.
Price: Medium to high, approaching $1000 for a series of weekly sessions over 3 to 4 months.
Simplicity: Medium. Frequent office visits are standard. Long-term compliance is likely to be low, given the small benefit and the inconvenience.
Knee braces
Recommended (SOR: C).
Safety: High.
Tolerability: Medium to high. Tolerance depends on the type of brace and its complexity.
Efficacy: Low to medium. Few studies of knee bracing have been done; however, 1 trial showed that 73% of those who used sophisticated taping for 3 weeks reported improvement, vs 10% of no-tape controls.9 Pain decreased by 2 points on a 0- to 10-point scale at 3 weeks, and the benefit persisted for an additional 3 weeks after the taping was discontinued. The taping used in the study is impractical for usual and long-term use, but 45% of those who used a sham taping/wrap reported improvement and about a 1-point decrease in pain at 3 and 6 weeks. This suggests that a less sophisticated wrap, such as an elastic patellar-stabilization sleeve, is likely to provide some benefit.
Price: Low (generally less than $30).
Simplicity: High (for a basic sleeve or wrap).
TENS
Recommended (SOR: B).
Safety/Tolerability: High. Withdrawals due to adverse effects of transcutaneous electrical nerve stimulation (TENS) range from 0% to 14%.10
Efficacy: Medium. The mean improvement with TENS is about 20 points more (on a 100-point scale) than the effect associated with placebo; the data are based on knee OA pain that is moderate to severe. The effect may last 2 to 4 weeks; however, there have been few long-term studies of the benefits of TENS.
Price: Low to medium, depending on availability and insurance coverage.
Simplicity: Medium; TENS units can be used at home, but some patients may be uncomfortable using the apparatus.
Injections/prescription drugs
Corticosteroid injections
Recommended (SOR: A).
Safety: High for short-term use, but data on the degree and frequency of acute post-injection pain is limited. The possibility of harm from repeated injections is similarly uncertain, although 1 study of patients receiving 8 injections over a 2-year period found no progression in ill effects compared with patients receiving placebo.11
Tolerability: Medium to high. Discomfort from the needle is usually mild.
Efficacy: Low to medium. Critical analysis supports a modest benefit, with an NNT of 2 to 3 for short-term improvement (lasting 3-4 weeks).12,13 In 1 study, steroid injections produced an average of a 16-point reduction in pain on a 100-point scale. After 1 month, the benefit from the injection is usually not clinically significant.
Price: Low ($100-$200 per injection).
Simplicity: High. The injection itself is a relatively simple procedure, but patient compliance with a scheduled course of repeat injections is uncertain.
Hyaluronic acid (HA) injections
Recommended with caveats (SOR: A).
Safety: High.
Tolerability: Medium. A small number of patients experience a transitory local flare-up. In addition, some patients have an aversion to injections.
Efficacy: Low. Several recent meta-analyses and systematic reviews of HA injections for knee OA have found a small, often negligible, clinical effect, with placebo usually accounting for up to half of the reported benefit.14-18 In 1 study with no control group, however, patients experienced about a 60% decrease in composite pain score—and 75% were satisfied or very satisfied with the treatment.19 Studies of HA injection for hip OA are very limited, but a recent single-injection trial showed no benefit over placebo.20
Any benefit from an HA injection generally lasts 3 to 4 months.
Price: Medium-high. A course of 3 injections costs $700 to $1000 per joint. There are claims of substantial savings due to delayed joint replacement, but these are speculative.
Simplicity: Medium. Compliance (completing all 3 injections) was high in clinical trials, but is uncertain otherwise. However, injections may frequently be useless because the joint space isn’t entered. One study found that 29% of knee injections were extra-articular; placement was uncertain in another 5%. There was no correlation between successful placement and presumed expertise. This error is not surprising, considering that the articular space is usually narrowed and patients being treated for joint pain are often obese. Being able to aspirate fluid increases the chance of proper placement. (While placement errors may also occur with corticosteroid injections, that possibility is offset by a lower cost and somewhat greater likelihood of beneficial effect.)
- Consider this option only for patients with high-function goals and substantial pain or disability.
- Proceed cautiously with morbidly obese patients and patients without effusion.
- Opt for bacterial HA (Euflexxa), which has been found to be the most cost effective and have the highest efficacy and the fewest adverse effects; evidence suggests that hylan (Synvisc) should be avoided.15,16
HA injections can be repeated every 6 to 12 months if they prove to be highly beneficial. Advise patients, however, that data on repeated courses of the injections are very limited.
Nonsteroidal anti-inflammatory gel or patch
Not recommended (SOR: B).
Safety: High. Absorption is minimal, but there may be some systemic effects.
Tolerability: Medium to high, although some patients develop skin reactions to the patch and the gel.
Efficacy: Low. Pain reduction of up to 50% has been reported, but most of it is attributed to the placebo effect. The actual effect of the gel or patch averages only about 10%.21-24
Price: Medium. The gel sells for $150 to $180 per month for a quantity large enough to be used on 2 hands or 1 knee; the patch is similarly priced.
Simplicity: Low. Manufacturers recommend that the gel be applied 4 times a day, but this can prove difficult over the long term. The patch is applied only twice a day, but the painful area is usually too large or irregular for the patch to cover.
Narcotics for refractory pain
Recommended (SOR: B).
Safety: Medium. The elderly are particularly vulnerable to narcotics’ adverse effects, but the incidence of addiction and abuse in geriatric patients is very low. Recently released guidelines on the management of persistent pain from the American Geriatrics Society recommend that all older patients with moderate to severe pain or diminished quality of life be considered for narcotic therapy.25
Tolerability: Medium. Noncompliance is associated with side effects, which are usually dose-dependent. These include constipation, somnolence, and mental status changes. Reported noncompliance rates vary, in some cases reaching as high as 30%.26
Efficacy: Low to medium for weak narcotics (eg, codeine, tramadol), with about a 10% decrease in pain.26,27 However, studies generally suffer from small numbers of patients, short duration, inconsistency among clinical trials, and limited evaluation of disability and quality of life. One good study of tramadol users showed about a 15% decrease in pain among “young elders”—the total decrease in pain was 30%, including the placebo effect. Sleep quality improved and tolerability was high, with no increase in withdrawal due to adverse effects.28 For stronger narcotics (eg, morphine), direct evidence of efficacy for OA pain is lacking, but it seems reasonable to expect a medium benefit. Low-to-moderate daily doses of opioids for chronic noncancer pain—including arthritis—have been shown to improve the quality of life, compared with no narcotics or high doses.29
Price: Low (less than $20/month) for hydrocodone with acetaminophen; medium to high (more than $150/month) for long-acting morphine and transdermal fentanyl.
Simplicity: Medium to high. Twice-a-day dosing is available for long-acting strong opioids, but some narcotics must be taken 4 times a day.
What else can you do? Encourage activity—again
A clear conclusion from many studies is that nonaquatic exercise involving the affected joints, either specifically or as part of a general exercise routine, is clinically beneficial in decreasing pain and increasing function.30 When it comes to aquatic exercises for OA, the data are very limited, but suggest a small short-term benefit.31 Overall, the optimal type and duration of exercise for OA patients, as well as the best location (home or at a gym), is not known.
If your patient has stopped or markedly cut down on the time spent exercising, explore the feasibility of another attempt, and discuss ways to improve compliance. Stress the “bonus” benefits of exercise, such as mood elevation and an overall sense of well-being. If the patient is not undergoing physical therapy, consider a referral.
Use a chronic pain approach
Patients whose OA symptoms continue to be troublesome may benefit from a chronic pain syndrome approach. Nurse case management, phone contact, and extra attention from you may be helpful, along with educational material that the patient can consult between visits (PATIENT HANDOUT).32
Treat insomnia. Studies are insufficient for hypnotics for OA symptoms, but good sleep is a goal of standard pain management. Cognitive-behavioral therapy has been found to be helpful in alleviating sleep problems in patients with OA.33 At a minimum, take a good sleep history and provide basic sleep hygiene education.
Treat vitamin deficiency and depression. Many elderly patients are deficient in vitamin D, and evidence indicates that supplementation supports muscle strengthening and may aid in pain reduction. The effects are mostly preventive, however, and therefore not easily appreciated, so stress the importance of long-term health.
Depression, too, is common among the elderly, particularly for chronic pain patients. If you prescribe antidepressants or vitamin supplementation, emphasize that they are “for your arthritis.”
Inspect footwear. Despite several studies regarding the effects of shoes with inserts on knee OA, it is unclear whether they provide clinical benefit. OARSI supports insoles for selected patients, but acknowledges that evidence is weak. Advise patients to select shoes that are flexible yet supportive and that moderately priced shoes appear to be as good as more expensive footwear for most OA patients. A podiatry consult may be beneficial for patients who have deformities of the feet or complain of foot pain.
Consider assistive devices. Patients with OA who are unstable may benefit from the use of a cane, walker, or other assistive device. Use common sense and individualize treatment, in consultation with an occupational therapist, if necessary.
Living with arthritis: Do’s and Don’ts
Osteoarthritis is an inflammation of the joint that affects many people as they age, mainly in the knees, hips, and hands. After many years of use, the cartilage that lines the inside of the joint thins and eventually wears off, leaving bone rubbing on bone. At the edge of the joint, the bone may grow into small “spurs” and fluid may increase inside, causing inflammation and pain.
There is no cure for arthritis. But there are many things that you and your doctor can do to make arthritis easier to live with, and to slow its progression. These Do’s and Don’ts may help:
Do get moving. Exercising your arthritic joints, except during acute flare-ups, will strengthen the muscles and help you stay active. Eventually you’ll find that you’re in less pain and can move about more easily.
Do consult a physical therapist to find out what type of exercise is best for you. Ask your doctor for a referral.
Don’t do those exercises during painful flare-ups. This is the time to give your joints a rest.
Do take acetaminophen (Tylenol), as needed, especially during flare-ups. You can take up to 4000 mg a day, but be sure to tell your doctor if you’re taking acetaminophen regularly.
Don’t take acetaminophen without first consulting your doctor if you have liver or kidney disease—or you’re taking a prescription pain medication.
Do ask your doctor about nonsteroidal anti-inflammatory drugs, sometimes called NSAIDs (pronounced N-SEDs). Some people benefit from ibuprofen (Advil, Motrin) or naproxen (Aleve), which are sold over-the-counter. Others take prescription NSAIDs such as Celebrex.
Don’t take NSAIDs without consulting your doctor if you’re over the age of 65. Both prescription and nonprescription NSAIDs can have serious side effects, and should be used with caution, if at all, by older people.
Do consider a trial of glucosamine (1500 mg daily), with or without chondroitin (1200 mg daily). Take it every day for 3 or 4 months without making other changes in treatment before you decide whether it’s working.
Don’t buy an expensive brand of glucosamine. The extra cost probably isn’t worth it.
Don’t take chondroitin without glucosamine, as it is unlikely to help.
Do apply ointments and rubs for pain relief. Start with capsaicin, which is available without a prescription. Buy the lowest strength you can find, and start by applying a very small amount on a small area because it may cause a burning sensation in the beginning. If you can’t tolerate capsaicin ointment, try a salicylate rub instead.
Do consider corticosteroid injections if you continue to have a lot of pain in your knee, especially if the doctor finds that you have fluid build-up. (If you don’t want to be injected with a steroid, ask your doctor if you’re a candidate for injections of hyaluronic acid, an artificial joint fluid that may help some patients.)
Do try TENS (transcutaneous electrical nerve stimulation) if you continue to have severe hip or knee pain. TENS therapy may be administered by a physical therapist, or with a device that you can use at home. A pad that emits a small tingle of electricity is placed over the painful joint to relieve the pain.
Do talk to your doctor about narcotic pain medication if your pain continues to be severe.
ADDITIONAL SELF-CARE TIPS:
Do try a wrap-around knee brace, which you can purchase at your local pharmacy. Ask your doctor about getting a cane or a walker if you need additional support.
Do alert your physician to certain conditions that can make your arthritis pain worse—insomnia, depression, or foot problems, for instance. And, if you have ill-fitting shoes or shoes that don’t provide much support, it’s time to replace them.
Joint replacement: When or whether?
Patients who are considering joint replacement surgery or are interested in learning more about it need a realistic picture of what to expect. Explain that results are usually—but not always—very favorable. However, surgery often brings greater improvement in pain than in function, and recovery can be very strenuous and lengthy. Infection rates average 1%,34,35 and mortality rates are low. In a large study of veterans, the 30-day mortality rates after knee and hip arthroplasty were 0.6% and 0.7%, respectively,36 but thromboembolic complications may occur despite prophylaxis. Overall, 5% of those undergoing joint replacement surgery develop significant complications.34,35
Knowing what surgery entails and the difficult recovery required may help patients be more tolerant of their OA symptoms. Whatever treatment your patients opt for, empathy on your part will help, as well.
CORRESPONDENCE
James Crosby, MD, United Health Services, Wilson Family Medicine Residency, 40 Arch Street, Johnson City, NY 13790; [email protected]
1. Ebell M, Siwek J. AFP: Doing more to help you get the best evidence. Am Fam Physician. 2004;69:483-484.
2. Mason L, Moore RA, Derry S, et al. Systematic review of topical capsaicin for the treatment of chronic pain. BMJ. 2004;228:991.-
3. Fox BA, Schmitz E, Wallace R. Glucosamine and chondroitin for osteoarthritis, Family Practice Inquires Network Clinical Inquires. Am Fam Physician. 2006;73:1245-1247.
4. Towheed TE, Maxwell L, Anastassiades TP, et al. Glucosamine therapy for treating osteoarthritis. Cochrane Database Syst Rev. 2005;(2):CD002946.-
5. Herrero-Beaumont G, Ivorra JA, Del Carmen TM, et al. Glucosamine sulfate in the treatment of knee osteoarthritis symptoms. Arthritis Rheum. 2007;56:555-567.
6. Clegg DO, Reda D, Harris CL, et al. Glucosamine, chrondroitin sulfate, and the two in combination for painful knee osteoarthritis. N Engl J Med. 2006;354:795-808.
7. Rozendaal RM, Koes BW, von Osch GJ, et al. Effect of glucosamine sulfate on hip osteoarthritis: a randomized trial. Ann Intern Med. 2008;148:268-277.
8. Manheimer E, Linde K, Lao L, et al. Meta-analysis: acupuncture for OA of the knee. Ann Intern Med. 2007;146:868-877.
9. Hinman RS, Crossley KM, McConnell J, et al. Efficacy of knee tape in the management of osteoarthritis of the knee: blinded randomised controlled trial. BMJ. 2003;327:135.-
10. Bjordal JM, Johnson MI, Lopes-Martins RA, et al. Short-term efficacy of physical interventions in osteoarthritic knee pain. A systematic review and meta-analysis of randomised placebo-controlled trials. BMC Musculoskelet Disord. 2007;8:51.-
11. Raynauld JP, Buckland-Wright C, Ward R, et al. Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial. Arthritis Rheum. 2003;48:370-377.
12. Arroll B, Goodinyear-Smith F. Corticosteroid injections for osteoarthritis of the knee: meta-analysis. BMJ. 2004;328:869-873.
13. Palacios L, Jones W, Mayo H. Do steroid injections help with osteoarthritis of the knee? J Fam Pract. 2004;53:921-922.
14. Bellamy N, Campell J, Robinson V, et al. Viscosupplementation for the treatment of osteoarthritis of the knee. Cochrane Database Syst Rev. 2006;(2):CD005321.-
15. Arrich J, Piribauer F, Mad P, et al. Intra-articular hyaluronic acid for the treatment of osteoarthritis of the knee: systematic review and meta-analysis. CMAJ. 2005;172:1039-1043.
16. Medina JM, Thomas A, Denegar CR. Knee osteoarthritis: should your patient opt for hyaluronic acid injection? J Fam Pract. 2006;55:669-675.
17. Modawal A, Fley J, Shukla R, et al. Hyaluronic acid injections relieve knee pain. J Fam Pract. 2005;54:758-767.
18. Waddell DD. Viscosupplementation with hyaluronans for osteoarthritis of the knee: clinical efficacy and economic implications. Drugs Aging. 2007;24:629-642.
19. Kichner M, Marshall D. A double-blind randomized controlled trial comparing alternate forms of high molecular weight hyaluronan for treatment of osteoarthritis of the knee. Osteoarthritis Cartilage. 2006;14:154-162.
20. Richette P, Ravaud P, Conrozier T, et al. Effect of hyaluronic acid in symptomatic hip osteoarthritis: a multicenter, randomized, placebo-controlled trial. Arthritis Rheum. 2009;60:824-830.
21. Underwood M. Advice to use topical or oral ibuprofen for chronic knee pain in older people: randomized controlled trial and patient preference study. BMJ. 2008;336:138-142.
22. Diclofenac gel for osteoarthritis. Medical Letter. 2008;50:31-32.
23. Lin J, Zhang W, Jones A, et al. Efficacy of topical non-steroidal anti-inflammatory drugs in the treatment of osteoarthritis: meta-analysis of randomized controlled trials. BMJ. 2004;329:324-329.
24. A diclofenac patch for pain. Medical Letter. 2008;50:1-2.
25. American Geriatrics Society. American Geriatrics Society announces new guidelines to improve pain management, quality of life, and quality of care for older patients. May 1, 2009. Available at: http://www.americangeriatrics.org/news/pain043009.shtml. Accessed June 1, 2009.
26. Peloso PM. Opioid therapy for osteoarthritis of the hip and knee: use it or lose it? J Rheum. 2001;28:6-10.
27. Bannwarth B. Letter: Opioids for osteoarthritis of the hip and knee: which opioids for which patients? J Rheum. 2001;28:1930-1931.
28. Vorsanger G, Xiang J, Jordan D, et al. Post hoc analysis of a randomized, double blind, placebo-controlled efficacy and tolerability study of tramadol extended release for the treatment of osteoarthritis pain in geriatric patients. Clin Ther. 2007;29:2520-2535.
29. Dillie KS, Fleming MF, Mundt MP, et al. Quality of life associated with daily opioid therapy in a primary care chronic pain sample. J Am Board Fam Med. 2008;21:108-117.
30. Fransen M, McConnell S, Bell M. Exercise for osteoarthritis of the hip or knee. Cochrane Database Syst Rev. 2003;(3):CD004376.-
31. Bartels EM, Lund H, Hagen KB, et al. Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database Syst Rev. 2007;(4):CD005523.-
32. Rosemann T, Joos S, Laux G, et al. Case management of arthritis patients in primary care: a cluster-randomized controlled trial. Arthritis Rheum. 2007;57:1390-1397.
33. Vitiello M. CBT for insomnia may reduce osteoarthritis pain. Poster presented at: 60th Annual Meeting of the Gerontological Society of America; November 16-20, 2007; San Francisco, Calif.
34. Erens G, Thronhill T. Complications of total hip arthroplasty. In: Basow DS, ed. UpToDate. Waltham, Mass: UpToDate; 2009. Available at: http://www.uptodate.com. Accessed May 20, 2009.
35. Martin G, Thornhill T. Complications of total knee arthroplasty. In: Basow DS, ed. UpToDate. Waltham, Mass: UpToDate; 2009. Available at: http://www.uptodate.com. Accessed May 20, 2009.
36. Ibrahim SA, Stone RA, Han X, et al. Racial/ethnic differences in surgical outcomes in veterans following knee and hip arthroplasty. Arthritis Rheum. 2005;52:3143-3151.
1. Ebell M, Siwek J. AFP: Doing more to help you get the best evidence. Am Fam Physician. 2004;69:483-484.
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6. Clegg DO, Reda D, Harris CL, et al. Glucosamine, chrondroitin sulfate, and the two in combination for painful knee osteoarthritis. N Engl J Med. 2006;354:795-808.
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8. Manheimer E, Linde K, Lao L, et al. Meta-analysis: acupuncture for OA of the knee. Ann Intern Med. 2007;146:868-877.
9. Hinman RS, Crossley KM, McConnell J, et al. Efficacy of knee tape in the management of osteoarthritis of the knee: blinded randomised controlled trial. BMJ. 2003;327:135.-
10. Bjordal JM, Johnson MI, Lopes-Martins RA, et al. Short-term efficacy of physical interventions in osteoarthritic knee pain. A systematic review and meta-analysis of randomised placebo-controlled trials. BMC Musculoskelet Disord. 2007;8:51.-
11. Raynauld JP, Buckland-Wright C, Ward R, et al. Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial. Arthritis Rheum. 2003;48:370-377.
12. Arroll B, Goodinyear-Smith F. Corticosteroid injections for osteoarthritis of the knee: meta-analysis. BMJ. 2004;328:869-873.
13. Palacios L, Jones W, Mayo H. Do steroid injections help with osteoarthritis of the knee? J Fam Pract. 2004;53:921-922.
14. Bellamy N, Campell J, Robinson V, et al. Viscosupplementation for the treatment of osteoarthritis of the knee. Cochrane Database Syst Rev. 2006;(2):CD005321.-
15. Arrich J, Piribauer F, Mad P, et al. Intra-articular hyaluronic acid for the treatment of osteoarthritis of the knee: systematic review and meta-analysis. CMAJ. 2005;172:1039-1043.
16. Medina JM, Thomas A, Denegar CR. Knee osteoarthritis: should your patient opt for hyaluronic acid injection? J Fam Pract. 2006;55:669-675.
17. Modawal A, Fley J, Shukla R, et al. Hyaluronic acid injections relieve knee pain. J Fam Pract. 2005;54:758-767.
18. Waddell DD. Viscosupplementation with hyaluronans for osteoarthritis of the knee: clinical efficacy and economic implications. Drugs Aging. 2007;24:629-642.
19. Kichner M, Marshall D. A double-blind randomized controlled trial comparing alternate forms of high molecular weight hyaluronan for treatment of osteoarthritis of the knee. Osteoarthritis Cartilage. 2006;14:154-162.
20. Richette P, Ravaud P, Conrozier T, et al. Effect of hyaluronic acid in symptomatic hip osteoarthritis: a multicenter, randomized, placebo-controlled trial. Arthritis Rheum. 2009;60:824-830.
21. Underwood M. Advice to use topical or oral ibuprofen for chronic knee pain in older people: randomized controlled trial and patient preference study. BMJ. 2008;336:138-142.
22. Diclofenac gel for osteoarthritis. Medical Letter. 2008;50:31-32.
23. Lin J, Zhang W, Jones A, et al. Efficacy of topical non-steroidal anti-inflammatory drugs in the treatment of osteoarthritis: meta-analysis of randomized controlled trials. BMJ. 2004;329:324-329.
24. A diclofenac patch for pain. Medical Letter. 2008;50:1-2.
25. American Geriatrics Society. American Geriatrics Society announces new guidelines to improve pain management, quality of life, and quality of care for older patients. May 1, 2009. Available at: http://www.americangeriatrics.org/news/pain043009.shtml. Accessed June 1, 2009.
26. Peloso PM. Opioid therapy for osteoarthritis of the hip and knee: use it or lose it? J Rheum. 2001;28:6-10.
27. Bannwarth B. Letter: Opioids for osteoarthritis of the hip and knee: which opioids for which patients? J Rheum. 2001;28:1930-1931.
28. Vorsanger G, Xiang J, Jordan D, et al. Post hoc analysis of a randomized, double blind, placebo-controlled efficacy and tolerability study of tramadol extended release for the treatment of osteoarthritis pain in geriatric patients. Clin Ther. 2007;29:2520-2535.
29. Dillie KS, Fleming MF, Mundt MP, et al. Quality of life associated with daily opioid therapy in a primary care chronic pain sample. J Am Board Fam Med. 2008;21:108-117.
30. Fransen M, McConnell S, Bell M. Exercise for osteoarthritis of the hip or knee. Cochrane Database Syst Rev. 2003;(3):CD004376.-
31. Bartels EM, Lund H, Hagen KB, et al. Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database Syst Rev. 2007;(4):CD005523.-
32. Rosemann T, Joos S, Laux G, et al. Case management of arthritis patients in primary care: a cluster-randomized controlled trial. Arthritis Rheum. 2007;57:1390-1397.
33. Vitiello M. CBT for insomnia may reduce osteoarthritis pain. Poster presented at: 60th Annual Meeting of the Gerontological Society of America; November 16-20, 2007; San Francisco, Calif.
34. Erens G, Thronhill T. Complications of total hip arthroplasty. In: Basow DS, ed. UpToDate. Waltham, Mass: UpToDate; 2009. Available at: http://www.uptodate.com. Accessed May 20, 2009.
35. Martin G, Thornhill T. Complications of total knee arthroplasty. In: Basow DS, ed. UpToDate. Waltham, Mass: UpToDate; 2009. Available at: http://www.uptodate.com. Accessed May 20, 2009.
36. Ibrahim SA, Stone RA, Han X, et al. Racial/ethnic differences in surgical outcomes in veterans following knee and hip arthroplasty. Arthritis Rheum. 2005;52:3143-3151.